Registration

Dear parents: Please fill in this form in its entirety so that we may have a full record of your child. Please fill out a separate form for each child you wish to send. If you have any questions or comments, please feel free to contact us at Chabad of Bethesda office:info@shalomchabad.comor 240-370-8819. Thank you and looking forward to seeing you this year!

STUDENT INFORMATION

Last Name First Name ﻿
Hebrew Name

Home Address

Home Phone
Email

DOB / /
Age
SchoolEntering Grade

Bar/Bat Mitzvah Date

PARENT INFORMATION

Fathers Name Hebrew Name

Occupation Work Address

Work Phone
HisEmail

Mothers Name Hebrew Name

Occupation
Work Address

Work Phone HerEmail

RELIGIOUS & EDUCATION INFORMATION

Synagogue Affiliation
Previous Hebrew School

Level of Hebrew Reading Proficiency:
None Basic Intermediate Advanced

Learning Disabilities? Yes No If yes, please describe:

Conversions or Adoptions in Family? Yes No If yes, please specify:

MEDICAL INFORMATION(Confidential)

Family Physician
Phone
Insurance Policy #

Up to date w/ vaccinations? Yes No Date of last tetanus:

Any special medical conditions?

Emergency Contact
Phone
Relation to Child

YEARLY FEE INFORMATION

Yearly fee for the year per child: $750 (this does not include additional trip/Shabbaton expenses) Discount: 10% off - each additional child registered

Method of payment: Full payment by Sep 15 1/2 by Sep 15, 1/2 by Jan 15 Special arrangement

Checks are CTeen Jr.'s preferred mode of payment, please make checks payable to 'Chabad of B-CC' all checks must be mailed to Chabad of B-CC, 5713 Bradley Blvd, Bethesda, MD 20814.

AGREEMENT

As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of B-CC CTeen Jr. to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, B-CC CTeen Jr. personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all activities, join in class and trips and beyond Chabad of Bethesda properties and allow my child to be photographed while participating in B-CC CTeen Jr. activities and that these pictures may be used for marketing purposes.